Karen Moore describes her relationship with parents in a self-deprecating tone: “I’m like the grim reaper to them.”

As school nurse for the Boundary County School District, Moore has a never-ending job: trying to persuade independent-thinking parents in a conservative community to keep their kids current on immunizations.

She sticks to constant themes. Immunizations can prevent the spread of life-threatening illnesses such as spinal meningitis. If a disease breaks out, the district can and will ban unvaccinated students from attending school.

“(Parents are) fine with that,” Moore said. “You cannot change their minds.”

Idaho law outlines — but doesn’t exactly require — a battery of immunizations. For kindergartners and first-graders, the list includes vaccinations covering diphtheria, tetanus and whooping cough; measles, mumps, and rubella; polio; hepatitis A and B; and chicken pox. For seventh-graders, the list also includes vaccinations for spinal meningitis and tetanus, diphtheria and whooping cough. However, parents can decide to opt out of immunizations. They can seek a medical exemption, with a doctor’s signature, or a religious exemption.

Moore says she cringes when she sees Boundary County’s dismal numbers: immunization rates that are among the lowest in Idaho, and immunization opt-out rates that are among the highest in the state.

But immunization isn’t just a touchy issue in the northernmost reaches of the Panhandle, and a county that shares a remote border with Canada. The law spells out what the state calls immunization requirements — but it gives parents veto power. Idaho’s immunization opt-out rates are among the highest in the nation, and that number continues to inch upward. And for the 2018-19 school year, it will be even easier for parents to say no.

The numbers — and what they mean

Tracking immunization rates is a tricky job, with much of the heavy lifting falling to the schools.

The schools are supposed to collect data for immunizations covering everything from hepatitis and whooping cough to measles and mumps. Each October, they round up data for kindergartners, first-graders and seventh-graders.

In 2017-18, about 61,000 of these students had a full battery of immunizations.

About 4,900 students were in school on an immunization exemption, an increase of about 400 students from the previous year. Most opt-outs are religious exemptions; some are medical exemptions.

Nearly 3,900 students were allowed to attend school, even though their immunization records were missing or incomplete.

Another 600 students were “conditionally admitted” into school, while their parents made plans to get their kids current on immunizations.

All of this adds up to an 87 percent immunization rate, a number that hasn’t changed in recent years. It’s a conservative estimate, and there’s no way to pin down a precise immunization rate. Even when parents file an exemption — or fail to turn in proper records — some of their kids might still have some or all of their immunizations.

But 87 percent is a long way from optimal.

“Research has shown that community vaccination rates of about 94 percent are necessary to protect against the spread of highly contagious, vaccine-preventable childhood diseases,” state superintendent Sherri Ybarra and Health and Welfare Director Russell Barron said in a joint letter in June. “If less than 94 percent of your students are immunized, some of them could be at risk of contracting potentially serious diseases.”

Patterns and problem areas

The latest numbers — compiled by the state and obtained by Idaho Education News — follow a few patterns.

Immunization rates generally skew higher in larger districts, particularly in the Treasure Valley and East Idaho. (Click here for immunization rates in Idaho’s 20 largest school districts.) Immunization rates are lower in charter schools and private schools. The Idaho Department of Health and Welfare hasn’t had a chance to analyze the reasons for this gap, said Rafe Hewett, manager of the agency’s Idaho Immunization Program.

Staffing can be an issue. Smaller schools sometimes struggle to piece together vaccination paperwork — especially during the hectic start of the year, and especially when a school doesn’t have a full-time nurse on staff. The numbers can vary widely. In a small school, all it takes is a few missing reports or a few opt-outs to skew the data.

Still, some of the 2017-18 results are sobering.

In 10 counties — Boise, Bonner,  Boundary, Camas, Clearwater, Custer, Idaho, Kootenai, Shoshone and Valley — immunization opt-out rates topped 10 percent. (Click here for the statewide map.)

At least 10 percent of immunization records were incomplete, or missing, in a dozen counties: Adams, Benewah, Blaine, Boise, Boundary, Butte, Gooding, Jerome, Kootenai, Lemhi, Lewis and Shoshone counties. In these communities, school principals and nurses have no easy way to confirm the immunization status for thousands of students — which is especially critical when a disease pops up.

Boundary County is a microcosm of the issue.

In 2017-18, barely a fifth of the district’s 124 seventh-graders had adequate immunizations. For nearly two thirds of these students, records were missing or incomplete.

“We do know that there’s work to be done there,” Hewett said.

Health and Welfare can provide training or technical assistance to districts or charters who ask for the help, he said. Moore says the state has been a good resource; its immunization database is helpful, and the state provides handouts and postcards that help schools get the word out.

In Boundary County, tracking isn’t the issue. Moore says the district knows exactly which parents haven’t turned in paperwork. Repeated requests often go unanswered. And when these parents send their children to school, the district cannot turn them away.

Incentives and consequences

Moore’s frustration stems from the fact that Boundary County has taken several steps to address the immunization problem.

At school registration, parents can get their kids vaccinated for free. The district works ahead of time to get the word out on immunizations. The district withheld class schedules for seventh-graders with missing or incomplete immunization records. That move didn’t go over well with parents or students, she said, but the district hasn’t ruled out trying it again.

If Boundary County can’t improve its immunization numbers, Moore at least wants better data.

Health and Welfare shares that sentiment. On the one hand, the agency encourages immunizations, in hopes of keeping serious diseases in check. On the other hand, Health and Welfare’s official position is to respect parental choice. The state wants complete numbers from the schools, Hewett said, “whatever they may be.”

Those numbers become crucial during a disease outbreak. This is the one time administrators can act assertively, and turn kids away from school. But without good data, Hewett said, schools would be left scurrying to respond to the crisis.

As is often the case with data, the immunization reports are a snapshot in time. The facts can change quickly — and this happened in 2015, when a measles outbreak at Disneyland drew national media attention.

“A lot of records showed up,” said Kathryn Turner, Health and Welfare’s deputy state epidemiologist.

A paperwork shortcut

Idaho’s immunization opt-out form isn’t exactly arduous — one page of checkboxes and spaces for signatures, and a second page for an optional parental statement.

In January, hardline conservative Sen. Dan Foreman pushed a bill to allow parents to skip the form and simply turn in a letter instead. The Moscow Republican’s bill went nowhere.

But in May, the state Board of Health and Welfare adopted an administrative rule that accomplishes the same purpose. While the state’s exemption form is simple, some parents have objected to it, Hewett said.

The new rule is in effect for 2018-19. It doesn’t seem like it has had a big impact in Boundary County — the school year doesn’t begin until Sept. 5 — but Moore is worried that the rule is a step in the wrong direction.

Lawmakers will still have the final word. But unlike a bill, which needs to clear both houses and then go to the governor’s desk, an administrative rule has an easier path to passage. Unless the Legislature actually rejects the new rule, it will go into effect permanently, and carry the weight of law.

On the edge of outbreak

As Treasure Valley parents are wrapping up their back-to-school shopping for 2018-19, health officials are warily watching for whooping cough.

They’ve seen a couple of outbreaks already, and 122 cases since the beginning of the year. The timing isn’t unusual — August is peak season for whooping cough — but it is problematic. If the disease spreads through a school, a student can easily bring the disease home. Infants are especially susceptible, Turner said, since immunizations don’t cover them fully until they are six months old.

Meanwhile, in Boundary County, Moore understands the situation all too well.

As she enters her seventh year at the Bonners Ferry-based district, she has a feel for her community. Many residents have an independent streak and a deep-seated concern about immunizations, and she is at a loss for how to change that sentiment. But after 35 years as a registered nurse, she knows that her unvaccinated students aren’t the only people at risk.

“They’re going to affect the entire area,” she said.